Medical Source Statement of Ability to Do Work-Related Activities (Mental)

Medical Source Statement of Ability to Do Work-Related Activities

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0662 can be found here:

Documents and Forms

Document Name Document Type
Form HA-1152 Medical Source Statement of Ability to Do Work-Related Activities (Mental) Form
HA-1152 Medical Source Statement of Ability to Do Work-Related A HA-1152-BK.pdf Form
HA-1152-BK.pdf Current HA-1152 IC Document

Information Collection (IC) Details

IC Title:	Medical Source Statement of Ability to Do Work-Related Activities (Mental)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 416.917 20 CFR 404.1513 20 CFR 404.1512 20 CFR 416.912 20 CFR 404.1517 20 CFR 416.913

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HA-1152	Medical Source Statement of Ability to Do Work-Related Activity (Mental)	HA-1152-BK.pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	150,000	30,000	120,000
Annual IC Time Burden (Hours)	37,500	7,500	30,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Current HA-1152	HA-1152-BK.pdf	09/19/2014

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.